Stanford
Prevention Policy Modeling Lab

Correctional Health

Research Area

Correctional Health

Click on a project title to learn more about PPML's work in Correctional Health.

Current Projects

Previous efforts toward HCV elimination within state Departments of Corrections have included a combination of guidelines and evidence, as well as legal pressure. To sustain momentum in states where action has been taken and to initiate HCV elimination strategies in other states, it is helpful to estimate, across states, what would be the likely costs and health benefits of universal HCV testing and treatment strategies in prisons. 

Through partnership with California Correctional Health Care Services, this study aims to model health and economic consequences associated with strategies to achieve HCV micro-elimination within California state prisons through the implementation of various interventions, such as universal HCV testing and treatment and substance use disorder treatment.

Persons who are justice system-involved are more likely to experience risk factors for hepatitis C and sexually transmitted infections (STI), and prevalence of these infections is higher than in the general population. For many incarcerated individuals, correctional health services may be the first or only touchpoint for testing and treatment. CDC recommends comprehensive opt-out testing at intake, treatment for those infected, and linkage to care upon release. Significant barriers exist for facilities to fully implement these recommendations. However, with dedicated resources and leadership support, some state department of corrections, jails, local health departments, and other community services have come together to overcome these barriers and implement successful programs tailored to their local situation.

Successful implementation of the CDC Recommendations for Correctional Settings across the nation could have important impacts on the community prevalence of these diseases and subsequent transmission. Decreasing the prevalence of these diseases among the incarcerated population and their communities could lead to improved population health and economic outcomes as well as safer work environment for correctional staff. Averted costs through reduced transmission could translate to increased funding to support the development and implementation of interventions and strategies to further reduce disparities in health outcomes for incarcerated populations.

This project will estimate the change in hepatitis C and syphilis national prevalence if all U.S. adult jails fully, successfully implemented the CDC Recommendations for Correctional Settings. It also aims to better understand the factors that could increase or decrease the health and economic impact of the CDC Recommendations and their collaboration with health departments.

Past Projects

As an increasing number of states begin to tackle state-wide hepatitis C elimination plans, the success of these initiatives is likely to depend on effectively addressing the high prevalence of HCV infection and its risk factors in correctional populations, including jails and prisons. Previous studies focused on evaluating a range of strategies for HCV testing and treatment in prisons and found that such strategies could provide high value for funds invested. Jails differ from prisons in ways that present logistical and cost challenges for scaling up HCV testing and treatment. Jail sentence durations are typically short, and most people who initiate HCV treatment in jail will need to be linked to a treatment provider in the community upon release. Jails typically do not have available resources to support large-scale HCV treatment or adequate infrastructure for monitoring patients and linking them to community care. 

This project focused on optimizing HCV testing and treatment strategies in jails and the associated clinical and public health benefits of different strategies. This included identifying testing and treatment implementation models that provide good value for the resources invested in scale-up and estimating budgetary impact from the jail perspective.

Moving toward the elimination of HCV infection in the United States will require achieving several targets for the HCV care cascade, such as diagnosing 90% of people living with chronic HCV infection, linking 90% of those diagnosed to care, and treating 80% of those for whom treatment is indicated. 

This project built on previous PPML work using the dynamic network simulation model of HCV transmission through injection equipment sharing to examine strategies for expanding HCV testing and treatment. The analysis compared the health and economic impact of HCV testing expansion in a range of key venues (correctional settings, emergency departments, syringe services programs, opioid treatment programs) and how specific venue features (e.g., percentage of clients who are PWID, access and utilization of the venue among PWID) influence the outcomes to inform decision making on venue utilization for hepatitis C elimination. Additionally, the analysis explores the potential synergy of combining HCV testing and treatment with harm-reduction services.

The prevalence of HCV in prisons is high, but the cost of HCV testing and treatment limits access to HCV treatment. Few correctional systems in the United States routinely test for HCV among inmates for fear of generating an unfunded mandate for treating those patients whom they identify as being HCV-infected. Before prisons can realistically plan to expand access to HCV care, they need a better estimate of the cost of doing so. 

PPML utilized its existing simulation of HCV in correctional settings to develop an end-user tool that correctional systems can use to estimate the budgetary impact of HCV testing and treatment in their system.

Associated Publication

There is a high prevalence of HCV in jails and prisons in the United States, but the limited availability and high cost of effective HCV treatments creates a dilemma for departments of corrections. Correctional facilities are constitutionally mandated to provide the “community standard” of medical care, but the cost of treating all HCV-infected patients in a given corrections system could exceed the entire healthcare budget for the system. This double liability has resulted in no clear direction for HCV screening and treatment guidelines.

This project utilized the Hepatitis C Cost-Effectiveness (HEP-CE) Model to compare four HCV screening and three HCV treatment strategies in incarcerated populations, in terms of clinical outcomes, budget impacts, and cost-effectiveness of these interventions. Building on the existing model structure that accommodates the epidemiology, natural history, and cascade of care associated with chronic HCV infection, the structure incorporated movement in and out of correctional facilities. This project provides a more generalizable framework for comparative evaluation of policies in a range of different settings.

Associated Publication